Sorting Out Depression in Diabetic Patients

Provocative new research suggests that some people living with diabetes may be misdiagnosed as being depressed.

Rather, the malaise they experience is the reaction to living with a stressful, complex disease that is often difficult to manage.

However, a second study of patients with type I diabetes emphasizes the potential importance of treating depressive symptoms regardless of their cause.

This study found that the greater depressive symptoms a patient reported, the higher that person’s mortality risk.

“Because depression is measured with scales that are symptom-based and not tied to cause, in many cases these symptoms may actually reflect the distress that people are having about their diabetes, and not a clinical diagnosis of depression,” said lead author Lawrence Fisher, Ph.D., A.B.P.P.

Fisher and his team developed measures of diabetes-specific distress that reflect whether a person had been feeling worried about a variety of problems associated with living with their diabetes, such as hypoglycemia.

They also asked patients to fill out the Patient Health Questionnaire to measure depressive symptoms.

Those who reported high levels of distress and high levels of depressive symptoms were assigned one of three interventions, all of which were designed to reduce the distress associated with managing diabetes, rather than symptoms of depression.

One group took part in an online diabetes self-management program. A second participated in the online program, and received individual assistance to problem solve issues related to their diabetes distress. A third was provided with personalized health risk information and then sent educational material about diabetes through the mail.

All groups received personal phone calls during the course of the project.

All three interventions significantly reduced distress as well as depressive symptoms over a 12-month period, and patients maintained those reductions over the course of the study.

“Overall, 84 percent of those scoring above 10 on the PHQ8 (maximum 27, with 10 being moderate depression) reduced their levels of depression to below 10 following the interventions,” Fisher said. Reductions were evenly distributed for all three interventions.

“What’s important about this,” said Fisher, “is that many of the depressive symptoms reported by people with type II diabetes are really related to their diabetes, and don’t have to be considered psychopathology. So they can be addressed as part of the spectrum of the experience of diabetes and dealt with by their diabetes care team.”

A second, unrelated study that analyzed data from a cohort of people with type I diabetes in the Pittsburgh area.

This study showed why it is so important to recognize depressive symptoms in people living with diabetes: Those who exhibit the highest level of depressive symptoms are most likely to die prematurely.

In the study, the Beck Depression Inventory was used to measure depressive symptoms such as low mood, losing interest in doing things, loss of appetite, feeling worthless, and having suicidal tendencies.

Participants in the study had been diagnosed with diabetes as children between 1950 and 1980, and were first studied in 1986. They are now in their 25th year of follow-up as part of a large, prospective cohort study.

“For every one point increase on the Beck Depression Inventory scale, participants showed a four percent increase in risk for mortality — after controlling for other factors that might increase the risk of death,” said Cassie Fickley, Ph.D., the lead author who analyzed these data as part of her doctoral degree.

“These data are very consistent with earlier findings from EDC which showed that greater depressive symptomatology predicted the incidence of heart disease in this cohort,” said Trevor Orchard, M.D., M.Med.Sci., the study’s principal investigator.

The earlier analysis was conducted by Cathy Lloyd, Ph.D., a co-author on the current paper, and currently a senior lecturer at the Open University in the UK.

Lloyd noted that “the data are relatively unique as the consequences of depression in type I diabetes are an understudied area of research.”

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Rick Nauert PhD

Dr. Rick Nauert has over 25 years experience in clinical, administrative and academic healthcare. He is currently an associate professor for Rocky Mountain University of Health Professionals doctoral program in health promotion and wellness. Dr. Nauert began his career as a clinical physical therapist and served as a regional manager for a publicly traded multidisciplinary rehabilitation agency for 12 years. He has masters degrees in health-fitness management and healthcare administration and a doctoral degree from The University of Texas at Austin focused on health care informatics, health administration, health education and health policy. His research efforts included the area of telehealth with a specialty in disease management.